Thyrotoxic Storm Following Thyroidectomy Follow-up
- Author: Peter F Czako, MD, FACS; Chief Editor: Arlen D Meyers, MD, MBA more...
Further Inpatient Care
Combined use of propylthiouracil, iodine, and dexamethasone has an effect within 24-48 hours, and the serum levels of T3 and T4 return to normal. Clinical signs of decreasing pulse, normal temperature, and improved mental status mark effective management. Complete recovery takes 10-12 days. Dexamethasone can be tapered thereafter.
The three modalities of definitive management are radioiodine, antithyroid drugs, and surgery.
Prior to radioiodine therapy or surgery, a patient should be made euthyroid with antithyroid drugs and propranolol. Antithyroid drugs are administered for 12-24 months, during which, a remission may occur. Antithyroid drugs are continued until a normal metabolic state is reached. If in remission, the patient should be closely monitored for 6 months, as relapse is more common during this period after discontinuation of therapy. Iodine is progressively withdrawn. Serially monitor patients until the thyroid gland is sufficiently depleted of its hormone to allow radioiodine therapy. Delaying radioiodine ablation for several months may be necessary because of the large doses of iodine used in management of thyroid storm. Some surgeons may reintroduce iodine for 10 days prior to surgery if subtotal thyroidectomy is planned. Follow patients for up to 5 years.
Criteria established by Burch and Wartofsky help in early recognition of impending storm. In thyroid storm, management as described improves the chance of survival.
Identification of precipitating factors
Surgery and anesthesia induction, labor, thioamide withdrawal, and use of radioiodine are known precipitants of thyroid storm. However, these precipitants may not be discovered frequently.
Precipitating factors are not found in all patients, but a meticulous search improves chances for a successful outcome.
Chest radiographs and blood, urine, and sputum cultures may be needed to identify intercurrent illness (eg, infection).
Judicious use of empiric antibiotics is needed if no obvious source is found.
Prevention of recurrence
Prevention of a recurrent crisis should be the main objective until completion of definitive therapy.
Vigilant monitoring of signs and symptoms of hyperthyroidism during preoperative or pre-anesthetic evaluation is paramount.
Consider precipitating factors when deciding on treatment modalities.
Adequate control of the thyrotoxic state prior to initiation of definitive therapy is important. Carry out procedures only after the patient is euthyroid.
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|Uncomplicated Thyrotoxicosis||Thyroid Storm|
|1. Heat intolerance, diaphoresis||1. Hyperpyrexia, temperature in excess of 106o C, dehydration|
|2. Sinus tachycardia, heart rate 100-140||2. Heart rate faster than 140 beats/min, hypotension, atrial dysrhythmias, congestive heart failure|
|3. Diarrhea, increased appetite with loss of weight||3. Nausea, vomiting, severe diarrhea, abdominal pain, hepatocellular dysfunction-jaundice|
|4. Anxiety, restlessness||4. Confusion, agitation, delirium, frank psychosis, seizures, stupor or coma|